While we are big advocates of non-drug treatments, many people do require the use of medications to control headaches. Headache medications are divided into two categories. Abortive drugs are those used as needed when the headache occurs. They are usually sufficient when headaches are infrequent. Prophylactic drugs are used for people with frequent attacks, and they are taken daily to prevent headaches.  Many patients express the concern that they will need to take daily medication for the rest of their lives.  This is not usually the case.  Daily prophylactic drugs are used until the headaches are under control, at which point they are weaned off.  The lowest effective dose is used for the shortest period possible.

Drug Treatment for Tension-type headaches 

Abortive medications such as painkillers and anti-inflammatory drugs are effective in treating tension-type headaches.  These medications should be limited to 2 to 3 days per week because using them more often can lead to an increase in frequency of attacks, or so called rebound headaches.  That’s why a limit of 15 to 20 tablets per month is placed on some of the combination drugs and strong pain killers.  Patients who need more than this amount generally need daily prophylactic medication.

a. Non-steroidal anti-inflammatory agents such as ibuprofen (Motrin, Advil), naproxen (Naprosyn, Anaprox), aspirin or aspirin/acetaminophen/caffeine combination (Excedrin) can be helpful in stopping a headache attack. 

b. Codeine or even stronger opioid medications may be required in a patient with occasional severe attacks. Chronic use of these medications in the treatment of headaches should be avoided. 

c. Drug combinations are often very effective for infrequent use. The combination of acetaminophen or aspirin with caffeine and a short acting barbiturate such as butalbital is very popular with many patients (Fiorinal, Fioricet, Esgic, Medigesic). 

d. Isometheptene is a drug that helps to reverse blood vessel abnormalities that occur during headaches.  It is available in combination with dichloralphenazone, a mild sedative, and acetaminophen (Midrin, Isocom). This combination can be effective in many patients who do not respond to other drugs. The main side effect is drowsiness. 

Prophylactic therapy 

Antidepressant drugs are the first-line treatment for severe and frequent headaches.  The most effective antidepressants are the tricyclic antidepressants (TCA) such as nortriptyline (Pamelor) or amitriptyline (Elavil).  Another group of antidepressants, the selective serotonin reuptake inhibitors (SSRIs), can be effective with fewer side effects. SSRIs include fluoxetine (Prozac), escitalopram (Lexapro), citalopram (Celexa), sertraline (Zoloft) and paroxetine (Paxil). Patients often prefer SSRIs because these drugs, unlike TCAs, are less likely to cause weight gain, constipation or excessive drowsiness.  However, they can cause sexual dysfunction, such as loss of libido or inability to reach an orgasm.

 

Propranolol, atenolol, nadolol and other beta blockers (a type of blood pressure medication) are less effective then TCAs in tension headaches but can be tried when other medications fail. Despite the fact that stress and tension are major causes of tension headaches, the use of tranquilizers should be avoided. Long-term use of these drugs can lead to addiction and worsening of headaches. Botulinum toxin (Botox) injections into the muscles around the head are being tested as a prophylactic therapy for chronic tension headaches. 

Abortive therapy 

Abortive therapy is used when the attacks are not very frequent. 

a. Non-steroidal anti-inflammatory agents mentioned above can be effective for migraine headaches. Fast action can be achieved by using an effervescent form of aspirin (Alka-Seltzer). 

b. Combination medications listed in the section on tension headaches can sometimes be effective. Addition of codeine to some of the combinations (Fiorinal with codeine and Fioricet with codeine) improves their efficacy for severe headaches. 

c. Ergots alone (Ergostat, sublingual) and with caffeine (Cafergot, tablets and suppositories, Wigraine, tablets) can be quite helpful too. These drugs can sometimes worsen or cause nausea. Reducing the dose, particularly of Cafergot suppositories, to one quarter or one half of a suppository can limit nausea and provide effective and rapid relief. Ergots cannot be used in pregnant women or patients with heart disease, high blood pressure, or other blood vessel problems. 

d. Dihydroergotamine (DHE-45) is effective for abortive treatment of migraines. This drug is available as an injection and a nasal spray.  A nasal spray form of dihydroergotamine (Migranal) is more convenient to take, but it is less effective. 

e. If nausea is present with the headache, anti-nausea medications can be given.  These come in the form of injections, tablets, and suppositories.  Some examples are prochlorperazine (Compazine) and metoclopramide (Reglan).

f. Triptans are a true breakthrough in the treatment of migraines. They are specifically developed to go to the source of the migraine and turn it off. They relieve not only the pain, but also all the associated symptoms of a migraine (such as nausea, light and sound sensitivity). These drugs are not identical, so if one does not work or causes side effects, another one in this group should be tried. There are seven available triptans, and many patients respond to only one of them.  The triptans are sumatriptan (Imitrex), zolmitriptan (Zomig), rizatriptan (Maxalt), naratriptan (Amerge), frovatriptan (Frova), eletriptan (Relpax), and almotriptan (Axert).  They differ in their time to effectiveness, length of effect, and side effect profiles.  All of these drugs are available as tablets, and Imitrex is also available in injection. Zomig and Imitrex are available in a nasal spray, while Maxalt and Zomig come in a “melt in your mouth” form.  The non-tablet forms are especially helpful for patients with severe nausea. 

Prophylactic therapy 

a. Tricyclic and other antidepressants can be as effective for migraine headaches as they are for tension-type ones. 

b. Blood pressure medications, such as propranolol, atenolol, nadolol and other beta-blockers (a type of blood pressure medications) are good prophylactic drugs. The effective dose for propranolol can be as low as 40 mg daily but is usually 80 to 240 mg. Patients with asthma, slow heart rates, heart block, congestive heart failure, and diabetes cannot use these drugs.  Calcium channel blockers (another type of blood pressure medication), such as verapamil (Calan) are sometimes effective for migraines, but are more likely to benefit a patient with cluster headaches.  ACE receptor blockers are newer blood pressure medications and one of them, candesartan (Atacand) has been proven in a clinical study to be very effective in preventing migraine attacks.

c. In some patients who do not respond to either a TCA or a beta-blocker alone, the combination of these two drugs together may stop the headaches. 

d. Antiepilepsy drugs, such as topiramate (Topamax) or divalproex sodium (Depakote) also relieve migraine headaches. Potential side effects include nausea, drowsiness and weight gain with Depakote or weight loss with Topamax. Topamax can also cause difficulty with memory and thinking.  Gabapentin (Neurontin) is a milder medication as far as side effects, but it is also somewhat less effective. 

e. NSAIDs can work well for prevention of migraines. 

f. Botulinum toxin (Botox) injections into the muscles around the head and neck is one of the most effective treatments for the prevention of migraines with hardly any side effects.  The effect lasts for 2-4 months.  (See chapter on Botox)

Pharmacological treatment for Cluster Headaches 

Abortive therapy 

The treatment of cluster headaches begins with reducing the pain of each attack while waiting for prophylactic drugs to take effect.  If cluster periods occur infrequently, the prophylactic drugs can be weaned off after the cluster period ends.

1. The most benign and often effective treatment is oxygen therapy.  The oxygen is inhaled through a mask for 10 to 15 minutes. It should be used for patients who get most of their attacks at home. If headaches occur during the day, patients can store another oxygen tank at work. 

2. Sumatriptan (Imitrex) injection is very effective in most patients and has few side effects. It can be self-administered by the patient using an auto-injector. 

3. Ergotamine (Cafergot, Wigraine, Ergostat) can stop a cluster headache in many patients. It is best given by a suppository to provide fast onset of action. Dihydroergotamine (DHE-45) is given only by injection and can also be self-administered by the patient.

1. A short course of corticosteroids (prednisone) will frequently stop the entire cluster episode. It is started at 80 mg daily and then is tapered down over a period of two weeks. 

2. Infusion of one gram of magnesium sulfate can also abort the cluster period in up to 40% of patients.

3. Occipital nerve block with a local anesthetic lidocaine and a long-acting corticosteroid Depo-Medrol can also abort a cluster period or at least provide several days of relief.

4. Calcium channel blockers such as nifedipine (Procardia) and verapamil (Calan, Isoptin) are started in patients who don’t respond to a course of prednisone. 

5. Antiepilepsy drugs, such as divalproex sodium (Depakote) 750-2000 mg daily and topiramate (Topamax) can be very effective. 

6. Lithium is a mood stabilizer which can work for both episodic and chronic forms of cluster headaches. Adding 2-4 mg of ergotamine a day to lithium may produce remission in patients who do not respond to lithium alone. 

7. Over-the-counter melatonin, 10 mg nightly has been reported to help a few patients with clusters. Intranasal capsaicin has been also used to prevent clusters. It is applied into the nostril on the side of the headache twice a day.